An 11-week-old infant boy, born prematurely and testing positive for cocaine at birth, was found unresponsive on the morning of July 31, 2023, by his legal paternal grandmother, who had court-ordered custody. The grandmother had fed him and put him to bed in his bassinet on his back around 11:40 p.m. the previous night. When she checked on him at approximately 5:30 a.m., she found him pale, cold, and unresponsive. The grandfather performed CPR while she called emergency services, and the infant was transported to the hospital where he was pronounced deceased. An autopsy found no injuries or evidence of trauma, and both the cause and manner of death were classified as undetermined. The fatality investigation was closed with no findings of maltreatment. At the time of death, the child was in a court-ordered placement with his paternal grandparents under an open judicial dependency case, after being removed at birth due to prenatal cocaine exposure.
Contexts/Conditions
Is there any mention of child drug ingestion or overdose?
Is there any mention of a drowning incident (either intentional or accidental)?
Is there any mention of a firearm incident?
Is there any mention of inappropriate supervision (e.g., child wandered off and drowned)?
Is there any mention of inflicted injury? (e.g. slapped, punched, kicked, choked)
Is there any mention of malnutrition, starvation, or dehydration?
Is there any mention of medical neglect?
The CIRRT report extensively discusses a medical neglect investigation: "A medical neglect investigation was received on June 15, 2023, alleging the legal paternal grandparents were not properly caring for injury to his hand." It further details that "The CPT conducted a medical evaluation and interviewed the paternal grandmother which resulted in indeterminate findings of medical neglect." The CPI also "determined there were indeterminate findings of medical neglect due to a lack of medical records provided and the inability to assess medical neglect solely on statements."
Is there any mention of a motor vehicle crash or incident?
Is there any mention of a murder-suicide incident?
Is there any mention of outdoor elements (including hot car deaths)?
Is there any mention of prenatal substance exposure (including fetal alcohol syndrome or neonatal abstinence syndrome)?
The CIRRT report states the child was removed "due to the mother and [child] testing positive for cocaine at his birth" and that the infant was admitted to the NICU. The Child Fatality Summary confirms "verified findings of substance exposed newborn and substance misuse-illicit drugs." Additionally, the grandmother's interview in the CIRRT report states the child was "born at 32 weeks gestation, weighing four pounds, and testing positive for cocaine."
Is there any mention of sexual abuse?
Is there any specific mention of shaken baby or abusive head trauma?
Is there any mention of prolonged abuse or torture (including restraints, captivity)?
Is there any mention of an unsafe sleeping environment?
Individuals Involved
Was an adoptive parent or guardian involved in the death?
Was a biological father involved in the death?
Was a biological mother involved in the death?
Was a day care worker, babysitter, or nanny involved in the death?
Was a female paramour or friend involved in the death (e.g., girlfriend, stepmother)?
Was a foster parent involved in the death?
Was a male paramour or friend involved in the death (e.g., boyfriend, stepfather)?
Was another adult relative involved in the death? (e.g., grandfather, aunt)
Was a sibling involved in the death?
Child Characteristics
Was the child adopted?
Was the child homeschooled (including "cyberschooling") or taken out of school?
Was the child in foster care at the time of the incident?
The child was formally removed from his parents by the court and placed with relatives under judicial oversight. The CIRRT report states "The death occurred during an open judicial case stemming from the child's removal in June of 2023" and the Child Fatality Summary confirms "The infant had been in a court-ordered placement with the paternal grandparents...since June 7, 2023, and he was receiving ongoing judicial case management services at the time of his death." The case was managed by Youth and Family Alternatives for case management. While the placement was with relatives rather than a traditional foster home, the child was in the dependency system under formal court-ordered out-of-home placement, which functionally constitutes foster/kinship care.
Was the child living with relatives at the time of the incident (but not parents)?
The CIRRT report states: "Upon discharge from the hospital, he was placed with the paternal legal grandparents, who were caring for his half siblings." The Child Fatality Summary confirms: "The infant had been in a court-ordered placement with the paternal grandparents (where the older siblings already resided) since June 7, 2023." The child was living with his legal paternal grandparents, not his parents, at the time of his death.
Is there any mention of a neurological developmental child disability? (e.g., autism, intellectual disability, nonverbal)
Is there any mention of a physical child disability? (e.g., feeding tube)
Is there any mention of prematurity or low birthweight?
The CIRRT report states the child was born "at 35 weeks gestation" in one section, and the grandmother's interview states the child "was born at 32 weeks gestation, weighing four pounds." While there is a discrepancy (35 vs. 32 weeks), both confirm prematurity. Four pounds also qualifies as low birthweight (below 5 lbs 8 oz / 2500g).
Is there a history of child protection reports prior to death (for this child or siblings)?
The CIRRT report states: "Between 2010 and 2023, the parents were involved in eight investigations with the Department to include patterns of domestic violence, substance use, and overall neglect." Additionally, "Between 2014 and 2023, the legal paternal grandparents were involved in six investigations that reflected patterns of physical injury and inadequate supervision." There were also investigations directly involving this infant prior to his death, including a verified investigation at his birth and a medical neglect investigation in June 2023.
Does the child have a history of foster care (but not in care at time of incident)?
Is there a history of a sibling death (separate incident from this death)?
Parent/Caregiver Factors
Was an adult charged or arrested for the child's death?
Is domestic violence by the parent/caregiver referenced?
The CIRRT report states: "both parents, ages 39 and 35 years, respectively, have an extensive history with patterns of substance use and domestic violence." It also states that between 2010 and 2023, the parents' eight investigations included "patterns of domestic violence."
Is there any mention that the death occurred in a temporary shelter or while homeless?
Is an intellectual disability of the parent/caregiver referenced?
Is the mental health of the parent/caregiver referenced?
Is a history of arrests or criminal charges for the parent/caregiver referenced?
Is substance use by the parent/caregiver referenced?
The CIRRT report extensively documents substance use by the parents: "both parents, ages 39 and 35 years, respectively, have an extensive history with patterns of substance use" and "the mother and [child] testing positive for cocaine at his birth." The father also "refused to participate in a drug screen." FIS workers were assigned to both parents for substance use treatment, though neither parent engaged.
Notable Details
The CIRRT report identifies a significant systemic policy conflict: the Department's operating procedure (CFOP 170-7) requires background screening of informal safety providers and specific activities for present danger safety plans, but this creates barriers when a child is hospitalized and the hospital serves as the de facto safety provider. The report notes "creating a safety plan when a child resides in a secondary location (i.e., hospital, shelter, or residential facility) which is common practice around the state, it doesn't align with the Department's operating procedure." The report also notes that "There was no documentation to support a conversation took place with the hospital staff, detailing the present danger safety plan" and "There was no indication the hospital staff were made aware of the safety plan and the expectations of their involvement." The Department was actively revising this procedure to address this systemic gap. Additionally, the review team explicitly determined "there was no correlation between the Department's previous involvement with the family and the circumstances surrounding the infant's death."
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